Monday, June 1, 2020

Interview with Dr. Jarvis Chen About Re-Opening Yoga Classes and Studios

And we are opening the gates by Nicholas Roerich
by Nina Zolotow

Now that some countries, including the US, are moving toward re-opening or partially re-opening after COVID-19 shutdowns, there has been a lot of conversation happening in the yoga community about when to re-open yoga studios and restart yoga classes, and how to do this safely. So, I decided to contact Dr. Jarvis Chen, a social epidemiologist at Harvard T.H. Chan School of Public Health as well as a Senior Intermediate 1 certified Iyengar yoga teacher, to see what his thoughts are on these issues. (See Interview with Dr. Jarvis Chen for Yoga Teachers and Yoga Students About COVID-19 for an earlier interview I did with Jarvis.)

Nina: In your opinion, how soon will it be—at the earliest—that yoga classes can safely return to normal? (By normal, I mean with students close together, shared props, teachers physically adjusting students, and all of the other things we used to do before the novel coronavirus.)

Jarvis: It seems that we are in a period of transition now; there’s a widespread sense that the extreme measures many areas took to severely reduce social contact have “flattened the curve” and we are starting to see the daily count of cases and deaths fall. That’s a good thing, and it’s true for some of the communities hardest hit, although not necessarily for all communities. But, in any case, our cultural conversation is turning to how do we relax shelter in place policies and begin to reopen the economy.

It is interesting that this is often couched in the language of “a return to normal.” People are understandably tired of social distancing—the kind of life that we’ve been living in shutdown mode is difficult to sustain, economically, practically, and emotionally. But it’s not a given that the end of sheltering in place means simply a “return” to the way things were.

One of yoga’s central teachings is that everything changes. This material world of prakṛti is impermanent and always changing (pariṇāmavāda) and we suffer when we remain attached to the way things were. So, it is important for us as yoga practitioners to question our attachment to how we used to live our lives, our aversion to some of the things we may continue to have to do to mitigate the risk of coronavirus transmission, and our fear of the unknown.

If we think about what would enable us to relax social distancing on a more permanent basis, one of the important concepts is the idea of herd immunity. If enough people develop immunity to COVID-19, either through having had and cleared the infection or through a vaccine, then at a certain threshold, enough people have immunity so that the effective reproductive number (the number of additional people a single infected person transmits to) is driven below 1 and transmission is interrupted.

There’s a simple mathematical relationship between the basic reproductive number, R0, and the herd immunity threshold = 1-(1/R0), so in general if R0 is 3, then we’d need 66% of the population to develop herd immunity. Some recent modeling research has hinted that this threshold might not need to be quite so high, but, unfortunately, it is unlikely that any community has achieved high enough levels of immunity from this first wave of infections for there to be herd immunity (Report 23: State-level tracking of COVID-19 in the United States). Even in places like New York and New Jersey, it’s likely that only about 16% (NY, NJ) or 13% (MA) of people have antibodies. And although these and other communities hardest hit in March, April, and May do have decreasing daily cases and deaths, many other states have steady or even increasing daily case counts (Coronavirus in the U.S.: Latest Map and Case Count).

The other way we can achieve herd immunity is through vaccination. Though there are some promising candidates in the pipeline, we are still many months away from a viable vaccine. And, once one is available, we will have to be able to distribute it equitably and convince people to take it.

Given this situation, even if we take steps now to relax shelter in place orders and open the economy, it is likely that we will have to be ready to re-impose lockdowns if the number of new cases and deaths starts to increase. So, I think rather than thinking about going “back to normal,” we have to think about creating a new normal that deals appropriately with the reality of our current situation. This includes maintaining basic hand washing and hygiene, wearing masks in public, maintaining social distance, and limiting contact with others in large groups. It also includes vigilance and an attention to new data as it becomes available, along with a willingness to change our behavior, including going back into lockdown if it becomes necessary.

Nina: Before there is a vaccine, in many communities, fitness classes, gyms, yoga classes, etc. will be allowed to reopen only with certain modifications to keep them safe. What do you think will be required to keep yoga classes safe if they resume during this interim period?

Jarvis: A lot of people have been thinking about this and coming up with creative proposals to try to mitigate risk if we start getting together for in-person yoga classes. Some would argue that the safest thing to do is to continue to stay at home—after all, self-isolation is the most certain strategy we can take to minimize risk. But we also know that behavioral absolutes are hard for people to maintain for an indefinite period of time. So, it’s important to talk about what kind of harm-reduction strategies we might be able to take to reduce our risk if we do leave the house.

Consciously talking about harm reduction is a kind of self-study (svādhyāya). It means looking into our own desires and motivations in order to weigh the risks we take. Behaviorally, we know it is helpful to do this in a mindful way so that we don’t just throw up our hands and say, “if it’s impossible to eliminate risk entirely, then let me just take all the risks!” Our desires and motivations play a major role in driving our behavior. So, we can ask ourselves, as a student, what is my reason for attending an in-person yoga class? Is it the sense of community? Is it my connection to my teacher? Is it an urge to get out of the house? As a teacher, what is my reason for teaching an in-person yoga class? Am I craving connection to my students? Do I want to help them with their yoga practice in a way that I would not be able to help them if they were practicing at home or in an online yoga format? Is it that I need to make a living?

All of these are valid reasons, but we have to be willing to look at them mindfully. If I decide that one of these reasons is important enough for me to want to attend or teach an in-person yoga class, then I have to turn my self-study to the impact of my actions. What are the consequences of my actions to myself and what are the consequences of my actions to others? Am I in a high-risk group for severe disease (based on age, chronic health issues) if I were to get infected? Do I live with someone who is at risk for severe disease if I were to bring it home? If there’s a chance that I am asymptomatic and go to a class, how would I feel if I inadvertently pass the virus to someone else? As a teacher in a class, even if I have taken precautions, how will I feel if someone becomes infected because they attended my class?

These concerns have to be weighed against the things we can reasonably do to organize yoga classes to reduce the risk of transmission. This is where the science comes in, and we do know more about the transmission of coronavirus than we did two months ago. We know that the major risk of transmission is via respiratory droplets and aerosols, and that this risk is much higher if we are indoors with someone who is infected for an extended period of time. While maintaining a distance of 6 ft helps to reduce the risk of coming into contact with these droplets, certain activities have the potential spread viral particles more widely, such as, talking loudly (Talking Can Generate Coronavirus Droplets That Linger Up to 14 Minutes), chanting, or singing (Coronavirus Ravaged a Choir. But Isolation Helped Contain It., High SARS-CoV-2 Attack Rate Following Exposure at a Choir Practice — Skagit County, Washington, March 2020).

Transfer of virus by touching surfaces appears to be less important as a route of transmission (Surfaces Are ‘Not the Main Way’ Coronavirus Spreads, C.D.C. Says), but this depends some on the type of surface, with infectious viral particles persisting longer on hard surfaces than soft surfaces such as paper or fabric (Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1, Stability of SARS-CoV-2 in different environmental conditions).

Because it’s possible to be infected but not show symptoms, it’s important to wear a mask when out in public (Respiratory virus shedding in exhaled breath and efficacy of face masks). Even an imperfect cloth mask provides “source control,” reducing the spread of respiratory droplets from someone with an active but perhaps unrecognized infection. Short of using an N95 mask, wearing a surgical or cloth mask is less effective at preventing you from being infected if you come in contact with someone who is actively shedding virus, but it is also a reminder not to touch your face and an important social cue (Personal Behavior Change).

Yoga Alliance has produced a document Re-Opening and Recovering: Best Practice Recommendations for Yoga Schools, Businesses, and Professionals with best practice recommendations for re-opening yoga studios, and I know many yoga teachers who have been working on coming up with sensible policies based on discussions with their colleagues and reading the literature. To give us some perspective, though, I will say that there is a lot that we still don’t know. While simulations and observational studies of particular outbreak situations have taught us a lot, we can’t really know how effective some of these strategies will be until we try them out and collect the kind of data that would enable us to evaluate them rigorously.

Nina: I, too, read the Yoga Alliance recommendations. Based on other research I’ve done, I thought they were very thorough but also quite onerous. So, I think our readers would appreciate your thoughts about several of the individual recommendations. Can we get your take on them one by one?

Let’s start with the big one. Should there be social distancing in the class? If so, how would the room need to be arranged?

Jarvis: Yes. I’ve heard of teachers marking out spaces in the studio with tape, and some are suggesting increasing the distance between mats to 8-10 ft. Often they’re increasing the space if they’re not requiring students to wear masks. I’ve also heard of teachers creating designated wall spaces for when students need to go to the wall for full arm balance or a standing pose.

Ventilation of indoor spaces is a big question, too. It’s clear that in poorly ventilated spaces, the risk of droplet and aerosol transmission is increased (Your Building Can Make You Sick or Keep You Well). So yoga studios should think about how they ventilate their spaces, and, if the air is recirculated, what kind of filtration systems are in place. It’s not entirely clear to me whether turning on a fan or opening a window is enough—it’s possible that if this ends up not bringing in fresh air and just recirculates the air in the room, this might actually increase the risk of infection.

Another idea in areas where the weather permits it would be to have yoga classes outside. In Light On Yoga, BKS Iyengar cautions against practicing yoga in direct sun, but perhaps yoga could be taught under a shade but open to the air on the sides, with appropriate social distancing.

Nina: What about the teacher and students wearing masks during class?

Jarvis: I think the “best practice” would be to wear a mask, given that we are indoors with other people for an extended period of time. If the teacher is talking and moving around the room, then it’s probably a good idea for the teacher to wear a mask.

Nina: What about students being asked not to talk during class to prevent droplets and aerosols?

Jarvis: Mask wearing would mitigate some of the risk of droplets and aerosols from students talking. But I think we also have to think about students breathing hard and expelling respiratory droplets, even if they are not talking, and also inhaling aerosolized droplets if they are breathing deeply. So, I would focus on mask wearing as the main strategy for preventing droplets and aerosols, whether from speaking or from breathing hard.

I have heard that some municipalities are stipulating that much more space would have to be allowed between students in fitness classes if masks are not worn. For example, Rhode Island’s Phase II guidelines for gyms stipulate that 14 feet of space is needed between individuals if they are not wearing a mask in a gym setting. I think this makes sense given the high risk presented by being in an enclosed space for an extended period of time with strangers.

Nina: What about screening teachers and students for temperature and/or symptoms before entering class?

Jarvis: Symptom screening is an important strategy used in many Asian countries who have been able to control their epidemics. In a recent New Yorker article (Amid the Coronavirus Crisis, a Regimen for Reëntry), Dr. Atul Gawande describes the daily screening his hospital does to check employees, patients, and visitors for symptoms of COVID-19 (A Web-based, Mobile Responsive Application to Screen Healthcare Workers for COVID Symptoms: Descriptive Study). So, it makes sense to screen students and teachers before they come into a yoga class (as long as we’re thoughtful about minimizing contact during the screening process!).

Nina: What about requiring students to use hand sanitizer before entering class? What about teachers?

Jarvis: It absolutely makes sense to make hand sanitizer widely available, preferably in a touchless dispenser, and to encourage students and teachers to use it frequently both before and during class. The question of “requiring” its use is interesting. How will you enforce the requirement?

Nina: What about the recommendations for cleaning between classes? Would studios or facilities need to clean the floors between every class as well as door handles, etc.? In some yoga classes students use walls for poses, so would those need to be cleaned as well? And is there anything else that might need disinfecting?

Jarvis: Frequent cleaning feels like something tangible that we can control, so yes, I think it makes sense for facilities to clean frequently touched surfaces between classes. Mopping the floor is something many studios already do between classes and wiping down door handles seems easy to add. Wiping down the walls seems a bit more of an undertaking, though, and may be less important given that people are not spending a lot of time in direct physical contact with the walls. But remember that touching surfaces is probably not so important a route of transmission (Surfaces Are ‘Not the Main Way’ Coronavirus Spreads, C.D.C. Says) so as long as teachers and students wash their hands or use hand sanitizer, they are probably okay.

Nina: Yoga Alliance recommended not using props at all. What do you think about this? This is a particular concern for the Accessible Yoga community, which relies on props to make yoga poses accessible, as well as anyone who teachers older students, etc. Can the studios realistically clean props? Or could people their bring their own? Or is it really best to not have props at all?

Jarvis: I’ve seen yoga teachers taking different approaches to the prop question. Not using props is an option, but many students need props to practice safely. If so, asking students to bring their own props is probably better than using common studio props. If a student brings their props and keeps them on their own mat, it is unlikely that there would be touch transmission to other students.

As I noted above, how long viral particles persist on surfaces depends on the material, with infectious particles recoverable after longer periods of time on hard surfaces than soft surfaces such as paper or fabric. It may be that hard surfaces could be wiped down after class and soft props could be put aside for approximately 3 days.

Again, for perspective, it’s unclear to me how effective heroic prop cleaning measures will be, compared with basic hand washing, social distancing, and mask wearing. Given that the main risks come from being in an enclosed space with others for an extended period of time, focusing on controlling the spread of droplets and aerosols seems more important.

Nina: What about students waiting to get into class? Would there need to be a special place and way for them to wait? And, when entering is okay, should there be protocols for how they enter the room? What about exiting from a class? Would there need to be protocols for that?

Jarvis: As many grocery stores have done, creating ways to control traffic flow into and out of the space makes sense. Again, wearing masks makes it possible to be in closer proximity to one another than not wearing masks.

Nina: What about the restrooms? Should they be used or kept closed? If used, what protocols should be followed for keeping them safe?

Jarvis: So long as restrooms are cleaned frequently, it’s probably important to keep restrooms open so that people are able to wash their hands.

Nina: What about payments to teachers? Should cash and checks be avoided? And are there any other recommendations for the process of checking in?

Jarvis: Again, here is where grocery stores have led the way. It makes sense to keep transactions contactless whenever possible. But cash and checks are probably okay, especially if the recipient puts the bills or paper aside for a few days before handling them.

Nina: Contact tracing is important for controlling the spread of COVID-19 and this is also something Yoga Alliance recommends preparing for. How can yoga studios prepare to deal with this so they can do the right things if they learn that a student or teacher has come down with the virus?

Jarvis: This is a really important point. Controlling the epidemic after relaxing shelter-in-place policies is really going to depend on good testing, identifying infected people, and contact tracing. It’s really important for yoga teachers and studios to keep good records of who was in class so if it turns out someone in class was infected, contact tracing can be done to identify all their possible contacts. Also, as we work to get better data on what mitigation practices work for in person yoga classes, it will be important to document what strategies yoga classes have implemented and whether not transmission occurs in those classes.

Nina: So far, we’ve been discussing studios and teachers. Let’s look at the student side for a moment. If you are a student who doesn’t feel safe or comfortable returning to class—even if precautions have been taken—what should you do?

Jarvis: If you don’t feel safe or comfortable returning to class, you absolutely should not feel that you have to! This goes for teachers as well as students. And for teachers, it would make sense to find out how your students are feeling about in-person classes before putting a lot of time, energy, and financial resources into creating new norms for class. A recent AP/NORC poll found that only about half of those who regularly went to restaurants, exercised at the gym, or traveled would feel comfortable doing so again (AP-NORC poll: Many in US won’t return to gym or dining out).

Nina: What are your own plans regarding your own yoga teaching? Are you going to try to create a “safe” yoga class during the period before there is a vaccine? Or are you going to wait until vaccines are widely available?

Jarvis: I feel fortunate that I’ve been able to stay at home and to continue to work and to teach online yoga classes. Teaching on Zoom is not my favorite—I miss connecting with my students and helping them with their practice in person. But my students tell me that they appreciate it and that it’s been helpful for them to be able to stay connected with our yoga community online. And I am happy to see that many of my students have been inspired to set up their yoga practice space at home. I hope that taking online yoga classes from their home practice space is making them more comfortable with doing yoga at home and that this will translate into them developing a home practice.

Most of my yoga students are older, putting them in the high-risk category for severe illness if they were to become infected. Frankly, I’m not so young either! So, I am not in a hurry to start up with in-person classes for the moment. I’m keeping my online yoga classes small and limited for the most part to students whom I have taught in person before we started sheltering in place. This makes it possible for me to give them individualized attention and for us to build on what they learned in my classes before.

I realize this is a huge luxury on my part—I have another job and I don’t depend on yoga teaching for my livelihood. I have enormous sympathy for yoga teachers who have been financially impacted by the shutdown and for studio owners who are struggling to pay their rent. I’m glad to see that some yoga organizations, such as Yoga Alliance and the Iyengar Yoga Association of New England, have created emergency relief funds to aid yoga teachers who have financial need and to help teachers find new ways to adapt their teaching to online formats.

Nina: Is there anything else at all that you would like to say?

Jarvis: I think it’s so important for us to be compassionate with ourselves and with others as we try to figure out how to move forward in our new reality. This is new territory for almost all of us, and it’s not surprising that there are differences of opinion about what to do. I have seen online discussions about how to think about re-opening yoga studios get very contentious as people come at them with different ideas about what is important and what is an acceptable level of risk to take. It is particularly challenging because the decisions we make about managing our own risk affect other people. It gets even more complicated because the ways in which coronavirus mitigation strategies have become politicized in the United States. This has eroded our social trust. And what I hear most often in the comments from both sides is a deep-seated fear of what other people are doing and a frustration around being unable to control things to conform to our ideas of how things should be. The reaction is to bring a lot of judgement and shaming to our interactions with others who want to take a different course of action than we do. Unfortunately, we know that shame is not an effective behavioral modification strategy.

Patañjali tells us that not only do we have to practice discipline (tapas) and self-study (śvādhyāya) in yoga, but we must also cultivate Īśvara-praṇidhāna. Classically, this is surrender to God, but perhaps we might translate this for our circumstances as giving up control over that which we were never able to control in the first place. Giving up that control creates space inside for compassion to take root. And compassion makes it possible for us to pause and to consider which desires and fears might be motivating others to act differently than we would like them to act. It does this because we practice pausing and considering what are the desires and fears that motivate our own actions.

This does not mean that all strategies and courses of action are going to be equally effective in preventing future coronavirus infections and deaths. As we try different things, the data will begin to make clear what is working and what is not working. It’s crucial that we be able to recognize what science is telling us and to communicate clearly about how our behaviors and social policies will have to change to accommodate reality. As spiritually engaged practitioners, this is our work: to see ourselves clearly, to understand our shared humanity, and to act in ways to reduce suffering in the world.

Dr. Jarvis Chen is a social epidemiologist at Harvard T.H. Chan School Of Public Health. His research focuses on social inequalities in health, and especially racial/ethnic and socioeconomic disparities in cancer outcomes. He is also a Senior Intermediate I certified Iyengar yoga teacher who lives, practices, and teaches in Boston. He studies with senior Iyengar yoga teacher Patricia Walden, whom he assists in classes and workshops. He also travels to Pune, India regularly to study with the Iyengars. In 2008, Jarvis was recognized by Yoga Journal as one of 21 teachers under the age of 40 who are “shaping the future of yoga.” See his Jarvis Chen Yoga Facebook page for more information.

This post was edited by Nina Zolotow, Editor in Chief of the Accessible Yoga blog.

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